Provider Demographics
NPI:1528228863
Name:WILSON, NELSON IV (CP)
Entity Type:Individual
Prefix:MR
First Name:NELSON
Middle Name:
Last Name:WILSON
Suffix:IV
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 E NORTHSIDE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-3663
Mailing Address - Country:US
Mailing Address - Phone:601-924-2888
Mailing Address - Fax:601-924-2885
Practice Address - Street 1:801 E NORTHSIDE DR
Practice Address - Street 2:SUITE D
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-3663
Practice Address - Country:US
Practice Address - Phone:601-924-2888
Practice Address - Fax:601-924-2885
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC364231744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management